colorectal

Surgeons expand the use of the surgical robot to benefit patients undergoing complex pancreatic and gastric operations.

Yanghee Woo, MD

Readers may have heard about surgical robots, which surgeons are using in increasing numbers across the country. At NewYork-Presbyterian/ Columbia, surgeons now use the surgical robot to perform gynecologic, urologic, colorectal, and a number of abdominal procedures. According to Yanghee Woo, MD, Assistant Professor of Clinical Surgery and Director, Global Center of Excellence in Gastric Cancer Care, it provides “phenomenal advantages” during operations to remove abdom­inal cancers, allowing surgeons to perform highly precise dissections, to retrieve lymph nodes without blood loss, and promoting faster recovery. She now performs almost all gastric (stomach) cancer operations with the surgical robot.

Based on Dr. Woo’s extensive training and clinical experience with the surgical robot, as well as careful observation of published data, the Division of Gastrointestinal (GI)/Endocrine surgery is now expanding its use of the robot to a broader range of pancreatic and abdominal operations. Together with John A. Chabot, MD, FACS, Chief, Division of GI/Endocrine Surgery and Executive Director, Pancreas Center, Dr. Woo performed the first robotic Whipple procedures at NYP/Columbia this year.

Methodical approach to adopting new technology

Dr. Chabot explains how the Division of GI/Endocrine Surgery has approached the prospect of incorporating the surgical robot into its toolbox.

“We have taken a very methodical approach in evaluating the surgical robot’s benefits in gastrointestinal and endocrine operations,” says Dr. Chabot. “Dr. Woo gained extensive experience during training with the world’s foremost experts in Korea. Following this, other surgeons in our division went through extensive, rigorous training. Once we had a well-trained team assembled, we then began choosing our cases very carefully in order to use the new technology in the safest way possible.” During this process of training and evaluation, some surgeons determined that using the robot did not offer sufficient benefits. James A. Lee, MD, Chief, Endocrine Surgery, found that it did not improve upon other methods of performing thyroid surgery. Dr. Woo found that using the robot to remove the gallbladder through a single incision was possible, but not worth the larger incision it required, especially to perform a surgery that is already so highly successful and low in risk. “There is no proven benefit in this instance, and the cost is significantly higher,” she says.

Benefits for complex abdominal surgery

However, the team has found the robot to be of great benefit for other types of procedures, including many colorectal, liver, and gastric operations. During complex operations, the robot is equipped with four arms that are inserted through small ports into the patient’s abdomen. The arm with surgical instrumentation is wristed, meaning that it can articulate in all directions. Another arm is equipped with three-dimensional, magnified camera technology that provides far better visualization than the two-dimensional visualization that is available during laparoscopic surgery. “These advances give us far more freedom of movement as well as precision” explains Dr. Chabot. Dr. Woo says that because of these capabilities, she is confident that she is able to do complex gastric operations better with the robot than without, even though studies have not yet confirmed her experience.

Initially, the GI/Endocrine division has used the surgical robot in patients with less advanced cancers or premalignant conditions. Patients could not have had any previous upper abdominal surgery, and their tumors could not be attached to major blood vessels that would require blood vessel reconstruction.

Although studies have not yet directly compared robotic and traditional abdominal operations, Dr. Chabot and Dr. Woo believe that the robot offers important advantages to patients by reducing surgical trauma overall. “We are seeing patients have shorter hospital stays and shorter recovery time overall. For patients with pancreatic cancer, one of the most important aspects is that this quicker recovery may allow them to start chemotherapy sooner than they otherwise would.”

On the horizon: improved visualization and surgical outcomes

“We have developed confidence in ourselves to do more advanced cases,” says Dr. Chabot. “Our primary goal has been to maintain safety by being prudent with this new technology.” With that foundation, the team anticipates that the surgical robot will facilitate important innovations in pancreatic surgery, particularly as it allows new forms of surgical visualization. New technologies under development include the use of various wavelengths of light and injected substances that allow surgeons to better detect the boundaries of tumors or to find disease that is not visible using natural light. These innovations may allow surgeons to perform cancer operations more effectively in the future, but they­ will require laparoscopic or robotic access. “The new tools coming down the line won’t be available through traditional incisions,” explains Dr. Chabot.

To learn more about pancreatic and GI/endocrine surgery, visit pancreasmd.org

New protocol to treat anal fissures offers excellent results, without cutting the muscle.

Daniel L. Feingold, MD

Sometimes the most difficult thing about a problem is overcoming the fear of facing it. When people have painful conditions of the anus, they tend to be embarrassed to talk about that part of the body and even less enthusiastic about inviting a doctor to take a look. But anal pain is best treated sooner than later, and an earlier diagnosis can improve patients’ outcomes in the long run.

Reflecting their commitment to doing everything possible to ease patients’ suffering, the surgeons in the Division of Colorectal Surgery at NewYork-Presbyterian/Columbia have recently developed a new protocol to treat anal fissures, a painful condition frequently misdiagnosed as hemorrhoids. What’s more, the new protocol offers superb results without cutting the anal sphincter muscle.

What are anal fissures?

Anal fissures are small cuts or tears at the skin of the anal opening. They typically cause pain when a person has a bowel movement, and pain can be severe for hours afterwards. Some patients also experience bleeding. Many people assume that pain in that part of the body signifies hemorrhoids, so they self-treat with hemorrhoid remedies first, says Daniel L. Feingold, MD, an attending surgeon in the Division since 2004. Very often, it is only after suffering for a long time that people finally seek help from a gastroenterologist or colorectal specialist.

According to Dr. Feingold, anal fissures can happen to anyone: the majority of patients are healthy, and fissures do not appear to have anything to do with age, gender, diabetes, smoking, diet, sexual practices, or any other known factors. Although some anal fissures heal without treatment, some do not, and these go on to cause chronic pain problems. The fissure cycle goes like this: if the cut of the fissure stays open, pain causes spasms of the muscles around the anus, which prevents blood flow to the area, which prevents healing. This leads to more pain and more spasm.

Medical therapy, primarily a muscle relaxant cream applied around the anus, is effective in healing about 70% of anal fissures. By relaxing the muscle so that spasms resolve, blood flow to the area improves and healing can occur. Hot baths and stool softeners can help promote healing. About 30% of patients fail to heal with this approach, however. These patients traditionally have had two options, the first of which is injection of botox into the fissure. By paralyzing a portion of the muscle and relaxing the spasm, the hope is that the fissure will heal. This works only in about 30% of patients, however. The gold-standard approach is a surgical procedure called sphincterotomy, in which the surgeon cuts a piece of the anal sphincter. This relaxes the spasm, which relieves the pain and allows nearly all fissures to heal. The drawback to sphincterotomy is that some people develop function-related problems, meaning that they can have increased urgency or impaired control of bowel movements, gas, etc. Women, in particular, are at risk of having function-related problems after sphincterotomy.

Why Columbia?

When patients first meet Dr. Feingold, he reassures them of several important things. First, he acknowledges that it is normal to feel embarrassed and anxious. Second, he explains that they are in the right place, where he and his colleagues are experts in colorectal conditions like anal fissures. Third, he emphasizes that his exam will be pain free; when evaluating a patient with a fissure, he does no internal exam, just a visual examination of the external anus. In fact, he says, “Many of my patients are surprised and ask, ‘That was it? That’s the whole exam?’”

Beneath his ability to help his patients feel comfortable and even laugh, Dr. Feingold means every word. To the point, he was so determined to find a better option for his patients with anal fissures that he took it upon himself to develop a new protocol to improve upon available treatment options.

Wound care protocol

Dr. Feingold performs the procedure in the operating room because it has the best lighting and allows patients to have sedation during the procedure. It takes about 15 to 20 minutes, and patients go home after a few hours.

The procedure entails four steps.

Gently dilate the anus with special retractors

Clean out the fissure with curettage to stimulate healing

Cauterize the wound with electrocautery to seal the wound

Inject traimcinolone (generic Kenalog), a steroid, into the fissure.

Dr. Feingold says that he developed the idea for the Kenalog protocol by considering the best-known approaches to treating chronic wounds. He has treated 115 patients with the new method, and virtually all have had superb outcomes. He is in the process of publishing results from his first 100 patients, two thirds of whom were pain free within ten days. Among the other third of patients, it took as long as six weeks for their pain to disappear. None of the patients have had control-related complications. “Patients report they are very happy with this approach,” says Dr. Feingold.

Dr. Feingold explains, “This has a good record of fixing the problem and a low risk profile. The beauty is that it is muscle-sparing, so it does not cause control-related problems. But it also doesn’t burn any bridges, so if it fails, it would still be possible to do a sphincterotomy, if need be.” Although he no longer performs sphincterotomies because of the success of this approach, other surgeons in the Division of Colorectal Surgery do, should it be needed.

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